GW1-2022-01179_Well Construction - GW1_20220124

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I�CL-1 D w j U LL'I 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
mumC
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable)
FROM TO DIAMETER THICAKN^ESrS MATERIAL
--Inc ft. ft. t5 in. /�oN P yG
Company Name (�J1 t
16.INNER CASINNG OR TUBING(geothermal closed-loop)
2.Well Construction Permit# IL1(O�[�FI�e71 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,[variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public
Geothermal(Heating/Cooling Supply) IN
Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t ft. O Q 4-Baco
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Q Stolmwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) "ROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
� `^��_^� �fde� 1 ft.
4.Date Well(s)Completed:L- Well ID#WQ(.b�f 0aM5 ft. t ft.
5a.Well Location: ft. UC ft.
Facility/frier Name Facility ID#(if applicable)
�7Yon St )V,I(e- .M u c_h Q K ic
C, � qO O
Physical Address,City,and Zip I ft. ft.
/_1nE4TW C ^^K� 44^ai'wt.t19'_M� 21.REMARKS
County 2 Parcel Identification No.(PIN))llY�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 'nn rr N W _1A
6.Is(are)the well(s) Permanent or Temporary Jwily'15A
ture of Ccrtified Well Contractor Date
ning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or NfNo NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a d explain the nature ofthe f this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: . (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use
��"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LP (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:A;R 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:690 EPA 26L Amount: c�a completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016